MEDICARE: GRAYSPACE COUNSELING GROUP, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist

General Provider Information

NPI Number	:	1457071912
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAYSPACE COUNSELING GROUP, INC

Provider Business Mailing Address
First Line	:	501 W BUTLER RD STE F
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29607-4846
Country	:	US
Telephone Number	:	864-309-0574
Fax Number	:

Provider Business Practice Location Address
First Line	:	501 W BUTLER RD STE F
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29607-4846
Country	:	US
Telephone Number	:	864-309-0574
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MICHELLE N SMITH
Credential	:	LPC
Telephone Number	:	864-266-3689

Provider Enumeration Date	:	09/02/2022
Last Update Date	:	09/02/2022

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